Flavia Giron Camerini

Segurança do paciente: análise do preparo de medicação intravenosa em hospital da rede sentinela

This study aimed to identify the frequency of errors occurring in intravenous medication preparation and to discuss the possible consequences of these errors to patients. This cross-sectional, observational survey was carried out in three units of one hospital, observing 365 intravenous drug doses prepared by 35 technicians. Data was collected in January and February of 2008. Errors rates above 70.00% were found in all units. The errors were grouped into the categories: needle exchange, ampoule disinfection, cleaning the countertop, wrong time, and wrong dose. The error rates were higher than 50.00% in all categories, except for wrong dose (6.58%). The microbiological safety of the procedure may have been affected, increasing the chance of patient harm in cases of solution contamination. Preparation at the wrong time, applying an hour early, occurred with tenoxicam and dipyrone. The stability of the medication may have been compromised, causing changes to the expected therapeutic results, opening further possibilty for undesirable consequences for patients.O estudo objetivou identificar a frequencia dos erros que ocorrem no preparo de medicamentos intravenosos.Pesquisa transversal de natureza observacional,em tres unidades de um hospital. Observaram-se 365 doses de medicamentos intravenosos preparadas por 35 tecnicos de enfermagem. A coleta de dados ocorreu entre janeiro e fevereiro de 2008. Encontraram-se taxas de erros acima de 70,00% em todas as unidades. Os erros foram agrupados nas categorias: troca de agulhas, desinfeccao de ampolas, limpeza da bancada e hora e dose erradas. As taxas de erro foram superiores a 50,00% em todas as categorias, com excecao de dose errada (6,58%). A seguranca microbiologica do procedimento pode ter sido afetada, aumentando a chance de dano ao paciente, em caso de contaminacao da solucao. O preparo na hora errada, com antecedencia de uma hora, ocorreu com tenoxicam e dipirona. A estabilidade dos medicamentos pode ter sido comprometida, causando mudancas no resultado terapeutico esperado, podendo ocorrer consequencias indesejaveis aos pacientes.

Análise da administração de medicamentos intravenosos em hospital da rede sentinela

This study aimed to identify errors type and their frequency that occur in the administration of intravenous medications. It is a cross-observational study in three units of a certain hospital. Intravenous drug doses, totaling 367, were observed and they were prepared by 35 nursing technicians. Data collection occurred from January to February, 2008. The errors were grouped into the categories medicine, patient, via, time, dose, phlebitis verification, and catheter patency. Results showed error rates in all sectors, over 80% for the categories Not conferring drug, Not evaluating the catheter patency and Not evaluating the phlebitis presence. Drug administration delayed in 69.75% of doses; probably it affected the therapeutic outcome of sodic ampicillin, furosemide, and tenoxicam. High errors rates may have caused changes in the expected therapeutic results and there may be unintended consequences to patients. DESCRITORS: Medication errors. Nursing. Patient Safety.The aim of the study was to identify the types and frequency of errors during the administration of intravenous medication. A Cross-sectional, observational study was carried out in three units of a hospital. Observations were conducted on 367 doses of intravenous medication, prepared by 35 nurse technicians. Data collection took place between January and August of 2008. Errors were grouped in the following categories: medication; patient; route; dosage; phlebitis check and catheter permeability. Results showed error rates present in all categories and of above 80% in the following: fail to check medication; fail to check catheter permeability; fail to check phlebitis presence. There were no errors related to route and dosage. Delayed medication in 69.75% of the doses possibly affected the expected therapeutic results of sodium ampicillin, furosemide and tenoxicam. The high error rates may have caused changes in the expected therapeutic result, giving chance for undesirable consequences for the patients DESCRIPTORS: Medication errors. Nursing. Patient safety.

Analisys the intravenous medication administration in sentinel network hospital

This study aimed to identify errors type and their frequency that occur in the administration of intravenous medications. It is a cross-observational study in three units of a certain hospital. Intravenous drug doses, totaling 367, were observed and they were prepared by 35 nursing technicians. Data collection occurred from January to February, 2008. The errors were grouped into the categories medicine, patient, via, time, dose, phlebitis verification, and catheter patency. Results showed error rates in all sectors, over 80% for the categories Not conferring drug, Not evaluating the catheter patency and Not evaluating the phlebitis presence. Drug administration delayed in 69.75% of doses; probably it affected the therapeutic outcome of sodic ampicillin, furosemide, and tenoxicam. High errors rates may have caused changes in the expected therapeutic results and there may be unintended consequences to patients. DESCRITORS: Medication errors. Nursing. Patient Safety.The aim of the study was to identify the types and frequency of errors during the administration of intravenous medication. A Cross-sectional, observational study was carried out in three units of a hospital. Observations were conducted on 367 doses of intravenous medication, prepared by 35 nurse technicians. Data collection took place between January and August of 2008. Errors were grouped in the following categories: medication; patient; route; dosage; phlebitis check and catheter permeability. Results showed error rates present in all categories and of above 80% in the following: fail to check medication; fail to check catheter permeability; fail to check phlebitis presence. There were no errors related to route and dosage. Delayed medication in 69.75% of the doses possibly affected the expected therapeutic results of sodium ampicillin, furosemide and tenoxicam. The high error rates may have caused changes in the expected therapeutic result, giving chance for undesirable consequences for the patients DESCRIPTORS: Medication errors. Nursing. Patient safety.

Patient safety: analysing intravenous medication preparation in a sentinel network hospital in brazil

This study aimed to identify the frequency of errors occurring in intravenous medication preparation and to discuss the possible consequences of these errors to patients. This cross-sectional, observational survey was carried out in three units of one hospital, observing 365 intravenous drug doses prepared by 35 technicians. Data was collected in January and February of 2008. Errors rates above 70.00% were found in all units. The errors were grouped into the categories: needle exchange, ampoule disinfection, cleaning the countertop, wrong time, and wrong dose. The error rates were higher than 50.00% in all categories, except for wrong dose (6.58%). The microbiological safety of the procedure may have been affected, increasing the chance of patient harm in cases of solution contamination. Preparation at the wrong time, applying an hour early, occurred with tenoxicam and dipyrone. The stability of the medication may have been compromised, causing changes to the expected therapeutic results, opening further possibilty for undesirable consequences for patients.O estudo objetivou identificar a frequencia dos erros que ocorrem no preparo de medicamentos intravenosos.Pesquisa transversal de natureza observacional,em tres unidades de um hospital. Observaram-se 365 doses de medicamentos intravenosos preparadas por 35 tecnicos de enfermagem. A coleta de dados ocorreu entre janeiro e fevereiro de 2008. Encontraram-se taxas de erros acima de 70,00% em todas as unidades. Os erros foram agrupados nas categorias: troca de agulhas, desinfeccao de ampolas, limpeza da bancada e hora e dose erradas. As taxas de erro foram superiores a 50,00% em todas as categorias, com excecao de dose errada (6,58%). A seguranca microbiologica do procedimento pode ter sido afetada, aumentando a chance de dano ao paciente, em caso de contaminacao da solucao. O preparo na hora errada, com antecedencia de uma hora, ocorreu com tenoxicam e dipirona. A estabilidade dos medicamentos pode ter sido comprometida, causando mudancas no resultado terapeutico esperado, podendo ocorrer consequencias indesejaveis aos pacientes.

Condutas dos profissionais de enfermagem frente aos alarmes dos ventiladores mecânicos em uma unidade de terapia intensiva

Objetivos: caracterizar quais alarmes sonoros disparados por ventiladores mecânicos foram mais frequentes, descrever o tempo estimulo-resposta aos alarmes do ventilador mecânico e analisar as condutas dos profissionais de enfermagem diante dos alarmes ventilatorios. Metodo: pesquisa descritiva, quantitativa, realizada em uma unidade de terapia intensiva de um hospital universitario do Rio de Janeiro. Os dados foram tratados com estatistica descritiva. Resultados: realizadas 60 horas de observacao, nesse periodo, soaram 25 alarmes de ventiladores mecânicos, 20 alarmes foram atendidos e 5 pararam sem nenhuma intervencao. Os alarmes mais prevalentes foram volume minuto expirado baixo, e pressao de vias aereas alta. O tempo minimo para atendimento dos alarmes foi 10 segundos, o tempo maximo 3 minutos, e o tempo medio 38 segundos. As condutas mais realizadas pelos profissionais de enfermagem foram aspiracao traqueal, reposicionamento do circuito e ausculta pulmonar. Conclusao: os achados da pesquisa apontaram que, nos alarmes mais prevalentes, as condutas dos profissionais de enfermagem, de acordo com a literatura, nao foram suficientes para a resolutividade dos problemas apresentados.

Safety in the use of infusor pumps: analysis of alarms

ABSTRACT Objective : to analyze the profile of the infusion pump alarms in an intensive unit. Method : this is a quantitative, descriptive, observational, cross-sectional and sectional study carried out in an intensive cardiogenic unit with a sample of 72 alarms fired from infusion pumps, collected in a structured instrument. The analysis was performed with tabulation and statistical treatment in SPSS® software version 2.1. and presented in figures. Results : it was observed that the alarms triggered by the infusion pumps are related to the end of infusion (41.7%) and the manipulation by the team (29.2%). Regarding the time of the alarms, the average of 109.8 seconds was identified, characterized by four alarms with more time: “pre-alarm end of infusion”, “low flow”, “end of standby” and “end of infusion”. Conclusion : the characterization of the alarms helps the nurse to plan actions to minimize the stimulus-response time, improving the quality of the nursing care and increasing the safety for the patient. Descriptors : Nursing Care; Patient Safety; Clinical Alarms; Nursing; Infusion Pumps; Healthcare. RESUMO Objetivo : analisar o perfil dos alarmes de bombas infusoras em uma unidade intensiva. Metodo : estudo quantitativo, descritivo, observacional, transversal e seccional, realizado em uma unidade cardio intensiva, com amostra de 72 alarmes disparados de bombas infusoras, coletados em instrumento estruturado. Analise realizada com tabulacao e tratamento estatistico no programa SPSS ® versao 2.1. e apresentados em figuras. Resultados : observou-se que os alarmes mais disparados pelas bombas infusoras estao relacionados ao fim de infusao (41,7%) e o de manipulacao pela equipe (29,2%). Em relacao aos tempos dos alarmes, identificou-se a media de 109,8 segundos, caracterizados por quatro alarmes com maior tempo: “pre-alarme fim de infusao”, “fluxo baixo”, “fim de stand by” e “fim de infusao”. Conclusao : a caracterizacao dos alarmes auxilia o enfermeiro a planejar acoes para minimizar o tempo estimulo - resposta, com a finalidade de melhorar a qualidade da assistencia de enfermagem e de aumentar a seguranca para o paciente. Descritores : Cuidados de Enfermagem; Seguranca do Paciente; Alarmes Clinicos; Enfermagem; Bombas de Infusao. RESUMEN Objetivo : analizar el perfil de las alarmas de bombas de infusion en una unidad intensiva. Metodo : estudio cuantitativo, descriptivo, observacional, transversal y seccional, realizado en una unidad cardio-intensiva, con muestra de 72 alarmas disparadas de bombas de infusion, recolegidas en instrumento estructurado. El analisis fue realizado con tabulacion y tratamiento estadistico en el programa SPSS ® version 2.1. y presentados en figuras. Resultados : se observo que las alarmas mas disparadas por las bombas de infusion estan relacionadas al fin de infusion (41,7%) y la de manipulacion por el equipo (29,2%). En relacion a los tiempos de las alarmas, se identifico la media de 109,8 segundos, caracterizados por cuatro alarmas con mayor tiempo: “pre-alarma fin de infusion”, “flujo bajo”, “fin de stand by” y “fin de infusion”. Conclusao : la caracterizacion de las alarmas auxilia al enfermero a planear acciones para minimizar el tiempo estimulo - respuesta, con la finalidad de mejorar la calidad de la asistencia de enfermeria y de aumentar la seguridad para el paciente. Descriptores : Atencion de Enfermeria; Seguridad del Paciente; Alarmas Clinicas; Enfermeria; Bombas de Infusion.

Análisis de la administracion de medicaciones intravenosas en hospital de red centinela

This study aimed to identify errors type and their frequency that occur in the administration of intravenous medications. It is a cross-observational study in three units of a certain hospital. Intravenous drug doses, totaling 367, were observed and they were prepared by 35 nursing technicians. Data collection occurred from January to February, 2008. The errors were grouped into the categories medicine, patient, via, time, dose, phlebitis verification, and catheter patency. Results showed error rates in all sectors, over 80% for the categories Not conferring drug, Not evaluating the catheter patency and Not evaluating the phlebitis presence. Drug administration delayed in 69.75% of doses; probably it affected the therapeutic outcome of sodic ampicillin, furosemide, and tenoxicam. High errors rates may have caused changes in the expected therapeutic results and there may be unintended consequences to patients. DESCRITORS: Medication errors. Nursing. Patient Safety.The aim of the study was to identify the types and frequency of errors during the administration of intravenous medication. A Cross-sectional, observational study was carried out in three units of a hospital. Observations were conducted on 367 doses of intravenous medication, prepared by 35 nurse technicians. Data collection took place between January and August of 2008. Errors were grouped in the following categories: medication; patient; route; dosage; phlebitis check and catheter permeability. Results showed error rates present in all categories and of above 80% in the following: fail to check medication; fail to check catheter permeability; fail to check phlebitis presence. There were no errors related to route and dosage. Delayed medication in 69.75% of the doses possibly affected the expected therapeutic results of sodium ampicillin, furosemide and tenoxicam. The high error rates may have caused changes in the expected therapeutic result, giving chance for undesirable consequences for the patients DESCRIPTORS: Medication errors. Nursing. Patient safety.

La seguridad del paciente: análisis de la preparación de medicamentos intravenosos en el hospital de la red sentinela

This study aimed to identify the frequency of errors occurring in intravenous medication preparation and to discuss the possible consequences of these errors to patients. This cross-sectional, observational survey was carried out in three units of one hospital, observing 365 intravenous drug doses prepared by 35 technicians. Data was collected in January and February of 2008. Errors rates above 70.00% were found in all units. The errors were grouped into the categories: needle exchange, ampoule disinfection, cleaning the countertop, wrong time, and wrong dose. The error rates were higher than 50.00% in all categories, except for wrong dose (6.58%). The microbiological safety of the procedure may have been affected, increasing the chance of patient harm in cases of solution contamination. Preparation at the wrong time, applying an hour early, occurred with tenoxicam and dipyrone. The stability of the medication may have been compromised, causing changes to the expected therapeutic results, opening further possibilty for undesirable consequences for patients.O estudo objetivou identificar a frequencia dos erros que ocorrem no preparo de medicamentos intravenosos.Pesquisa transversal de natureza observacional,em tres unidades de um hospital. Observaram-se 365 doses de medicamentos intravenosos preparadas por 35 tecnicos de enfermagem. A coleta de dados ocorreu entre janeiro e fevereiro de 2008. Encontraram-se taxas de erros acima de 70,00% em todas as unidades. Os erros foram agrupados nas categorias: troca de agulhas, desinfeccao de ampolas, limpeza da bancada e hora e dose erradas. As taxas de erro foram superiores a 50,00% em todas as categorias, com excecao de dose errada (6,58%). A seguranca microbiologica do procedimento pode ter sido afetada, aumentando a chance de dano ao paciente, em caso de contaminacao da solucao. O preparo na hora errada, com antecedencia de uma hora, ocorreu com tenoxicam e dipirona. A estabilidade dos medicamentos pode ter sido comprometida, causando mudancas no resultado terapeutico esperado, podendo ocorrer consequencias indesejaveis aos pacientes.